Provider Demographics
NPI:1770808578
Name:THE LIFE CENTER COMPLEX, INC
Entity type:Organization
Organization Name:THE LIFE CENTER COMPLEX, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MBA
Authorized Official - Phone:302-552-3574
Mailing Address - Street 1:812 PHILADELPHIA PIKE STE F
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-2371
Mailing Address - Country:US
Mailing Address - Phone:302-407-5316
Mailing Address - Fax:302-552-3561
Practice Address - Street 1:1624 JESSUP ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-4210
Practice Address - Country:US
Practice Address - Phone:302-552-3574
Practice Address - Fax:302-552-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE71788103TP2701X
DE261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1770808578Medicaid